Provider Demographics
NPI:1679659817
Name:MORENO, JAIME PATRICIO (L PHYSICAL THERAPY)
Entity Type:Individual
Prefix:MR
First Name:JAIME
Middle Name:PATRICIO
Last Name:MORENO
Suffix:
Gender:M
Credentials:L PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 331358
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78463-1358
Mailing Address - Country:US
Mailing Address - Phone:361-879-0006
Mailing Address - Fax:361-879-0702
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-3420
Practice Address - Country:US
Practice Address - Phone:361-879-0006
Practice Address - Fax:361-879-0702
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1086924225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX087781301Medicaid
TX087781301Medicaid
TX1086924Medicaid